|Care in Normal Birth (WHO, 1996, 60 p.)|
|4. CARE DURING THE SECOND STAGE OF LABOUR|
|4.7 Care of the Perineum|
Perineal tears occur frequently, especially in primiparous women. First-degree tears sometimes do not even need to be sutured, second-degree tears usually can be sutured easily under local analgesia, and as a rule heal without complications. Third-degree tears can have more serious consequences and should, where at all possible, be sutured by an obstetrician in a well-equipped hospital, in order to prevent faecal incontinence and/or faecal fistulas.
Episiotomies are often made, but the incidence is diverse. In the USA they are carried out on between 50 and 90% of women giving birth to their first child, thus making the episiotomy the most commonly performed surgical procedure in that country (Thacker and Banta 1983, Cunningham et al 1989, Woolley 1995). In many centres blanket policies, such as a requirement for all primiparous women to have an episiotomy, are in place. In the Netherlands midwives attain an overall frequency of 24.5% episiotomies, 23.3% of which are mediolateral and 1.2% midline episiotomies (Pel and Heres 1995). Midline episiotomies are more easily sutured and have the advantage of leaving less scar-tissue, whilst mediolateral episiotomies more effectively avoid the anal sphincter and the rectum. Good reasons for performing an episiotomy during a thusfar normal delivery can be: signs of fetal distress; insufficient progress of delivery; threatened third-degree tear (including third-degree tear in a previous delivery).
All three indications are valid, although the prediction of a third-degree tear is very difficult. The incidence of third-degree tears is about 0.4%, and the diagnosis threatened third-degree tear should therefore only be made occasionally, otherwise the diagnosis is meaningless.
In the literature several reasons, besides the above-mentioned, are given for a liberal use of episiotomy. These include the arguments that it substitutes a straight, neat surgical incision for a ragged laceration, it is easier to repair and heals better than a tear (Cunningham et al 1989); that liberal use of episiotomy prevents serious perineal trauma; that episiotomies prevent trauma to the fetal head; and that episiotomies prevent trauma to the muscles of the pelvic floor, and thus prevent urinary stress incontinence.
The evidence to support these postulated benefits of a liberal use of episiotomy has been investigated in several randomized trials (Sleep et al 1984, 1987, Harrison et al 1984, House et al 1986, Argentine episiotomy trial 1993). The data from these trials do not give evidence to support this policy. Liberal use of episiotomy is associated with higher rates of perineal trauma, and lower rates of women with an intact perineum. The groups of women with liberal and restricted use of episiotomy experienced a comparable amount of perineal pain assessed at 10 days and 3 months post partum. There is no evidence of a protective effect of episiotomy on the fetal condition. In a follow-up study up to three years postpartum no influence of a liberal use of episiotomies on urinary incontinence was found. In an observational study of 56.471 deliveries attended by midwives the incidence of third-degree tears was 0.4% if no episiotomy was made, and the same with a mediolateral episiotomy; the incidence with a midline episiotomy was 1.2% (Pel and Heres 1995).
The caregiver who makes the episiotomy should be able to suture tears and episiotomies appropriately. He or she should be trained accordingly. An episiotomy should be made and sutured under local anaesthesia, with proper precautions for the prevention of HIV and hepatitis infection (see 2.8).
In conclusion, there is no reliable evidence that liberal or routine use of episiotomy has a beneficial effect, but there is clear evidence that it may cause harm. In a thusfar normal delivery there may at times be a valid indication for an episiotomy, but a restricted use of this intervention is recommended. The percentage of episiotomies attained in the English trial (10%) without harm to the mother or the infant (Sleep et al 1984) would be a good goal to pursue.